Group Practice Registration
* Represent Mandatory Fields
Practice Information
Tax ID * NPI
Practice Name *
If you have website for your practice, enter URL:
Practice Primary Location
Location Type Primary
Address 1 *
Address 2
Zip * - State *
City * County
Phone # * Fax #
Practice Administrator / Contact Person Information
Salutation *
Last Name *
First Name *
MI DOB *
Phone # * Fax #
Primary Email *
Confirm Primary Email *
Secondary Email
Confirm Secondary Email
Practice Administrator Account Information
User ID *
Security Question 1 *
Answer 1 *
Security Question 2 *
Answer 2 *
Security Question 3 *
Answer 3 *
Security Code
Securty Code
Characters *




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